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NASA NTRS1997

Demonstration of a Safety Analysis on a Complex System

For the past 17 years, Professor Leveson and her graduate students have been developing a theoretical foundation for safety in complex systems and building a methodology upon that foundation. The methodology includes special management structures and procedures, system hazard analyses, software hazard analysis, requirements modeling and analysis for completeness and safety, special software design techniques including the design of human-machine interaction, verification, operational feedback, and change analysis. The Safeware methodology is based on system safety techniques that are extended to deal with software and human error. Automation is used to enhance our ability to cope with complex systems. Identification, classification, and evaluation of hazards is done using modeling and analysis. To be effective, the models and analysis tools must consider the hardware, software, and human components in these systems. They also need to include a variety of analysis techniques and orthogonal approaches: There exists no single safety analysis or evaluation technique that can handle all aspects of complex systems. Applying only one or two may make us feel satisfied, but will produce limited results. We report here on a demonstration, performed as part of a contract with NASA Langley Research Center, of the Safeware methodology on the Center-TRACON Automation System (CTAS) portion of the air traffic control (ATC) system and procedures currently employed at the Dallas/Fort Worth (DFW) TRACON (Terminal Radar Approach CONtrol). CTAS is an automated system to assist controllers in handling arrival traffic in the DFW area. Safety is a system property, not a component property, so our safety analysis considers the entire system and not simply the automated components. Because safety analysis of a complex system is an interdisciplinary effort, our team included system engineers, software engineers, human factors experts, and cognitive psychologists.

Leveson, Nancy↗
NASA NTRS2000

Aerospace Safety Advisory Panel Annual Report for 1999

This report covers the activities of the Aerospace Safety Advisory Panel (ASAP) for the calendar year 1999.This was a year of notable achievements and significant frustrations. Both the Space Shuttle and International Space Station (ISS) programs were delayed.The Space Shuttle prudently postponed launches after the occurrence of a wiring short during ascent of the STS-93 mission. The ISS construction schedule slipped as a result of the Space Shuttle delays and problems the Russians experienced in readying the Service Module and its launch vehicle. Each of these setbacks was dealt with in a constructive way. The STS-93 short circuit led to detailed wiring inspections and repairs on all four orbiters as well as analysis of other key subsystems for similar types of hidden damage. The ISS launch delays afforded time for further testing, training, development, and contingency planning. The safety consciousness of the NASA and contractor workforces, from hands-on labor to top management, continues high. Nevertheless, workforce issues remain among the most serious safety concerns of the Panel. Cutbacks and reorganizations over the past several years have resulted in problems related to workforce size, critical skills, and the extent of on-the-job experience. These problems have the potential to impact safety as the Space Shuttle launch rate increases to meet the demands of the ISS and its other customers. As with last year's report, these work- force-related issues were considered of sufficient import to place them first in the material that follows. Some of the same issues of concern for the Space Shuttle and ISS arose in a review of the launch vehicle for the Terra mission that the Panel was asked by NASA to undertake. Other areas the Panel was requested to assess included the readiness of the Inertial Upper Stage for the deployment of the Chandra X-ray Observatory and the possible safety impact of electromagnetic effects on the Space Shuttle. The findings and recommendations in this report do not highlight any major, immediate issues that might compromise the safe pursuit of the various NASA programs. They do, however, cover concerns that the Panel believes should be addressed in the interest of maintaining NASA's excellent safety record.The Panel is pleased to note that remedial efforts for some of the findings raised are underway. Given appropriate funding and cooperative efforts among the Administration, the Congress and the various contractors, the Panel is convinced that safety problems can be avoided or solved resulting in lower risk for NASA's human space and aeronautics programs. Section II of this report contains specific findings and recommendations generated by Panel activities during the calendar year 1999. Section III presents more detailed information in support of these findings and recommendations. A current roster of Panel members, consultants, and staff is included as Appendix A. Appendix B contains NASA's response to the findings and recommendations from the 1998 annual report. It has been augmented this year to include brief explanations of why the Panel classified the NASA response as " open,""continuing," or "closed." Appendix C lists the fact-finding activities of the Panel in 1999.

Blomberg, Richard D.↗
NASA NTRS2001

A Synthetic Vision Preliminary Integrated Safety Analysis

This report documents efforts to analyze a sample of aviation safety programs, using the LMI-developed integrated safety analysis tool to determine the change in system risk resulting from Aviation Safety Program (AvSP) technology implementation. Specifically, we have worked to modify existing system safety tools to address the safety impact of synthetic vision (SV) technology. Safety metrics include reliability, availability, and resultant hazard. This analysis of SV technology is intended to be part of a larger effort to develop a model that is capable of "providing further support to the product design and development team as additional information becomes available". The reliability analysis portion of the effort is complete and is fully documented in this report. The simulation analysis is still underway; it will be documented in a subsequent report. The specific goal of this effort is to apply the integrated safety analysis to SV technology. This report also contains a brief discussion of data necessary to expand the human performance capability of the model, as well as a discussion of human behavior and its implications for system risk assessment in this modeling environment.

Hemm, Robert↗
NASA NTRS2000

A Safety Index and Method for Flightdeck Evaluation

If our goal is to improve safety through machine, interface, and training design, then we must define a metric of flightdeck safety that is usable in the design process. Current measures associated with our notions of "good" pilot performance and ultimate safety of flightdeck performance fail to provide an adequate index of safe flightdeck performance for design evaluation purposes. The goal of this research effort is to devise a safety index and method that allows us to evaluate flightdeck performance holistically and in a naturalistic experiment. This paper uses Reason's model of accident causation (1990) as a basis for measuring safety, and proposes a relational database system and method for 1) defining a safety index of flightdeck performance, and 2) evaluating the "safety" afforded by flightdeck performance for the purpose of design iteration. Methodological considerations, limitations, and benefits are discussed as well as extensions to this work.

Latorella, Kara A.↗
NASA NTRS2005

International Cooperation in the Field of International Space Station (ISS) Payload Safety

In the frame of the International Space Station (ISS) Program cooperation, in 1998, the European Space Agency (ESA) approached the National Aeronautics and Space Administration (NASA) with the unique concept of a Payload Safety Review Panel (PSRP) "franchise" based at the European Space Technology Center (ESTEC), where the panel would be capable of autonomously reviewing flight hardware for safety. This paper will recount the course of an ambitious idea as it progressed into a fully functional reality. It will show how a panel initially conceived at NASA to serve a national programme has evolved into an international safety cooperation asset. The PSRP established at NASA began reviewing ISS payloads approximately in late 1994 or early 1995 as an expansion of the pre-existing Shuttle Program PSRP. This paper briefly describes the fundamental Shuttle safety process and the establishment of the safety requirements for payloads intending to use the Space Transportation System and International Space Station (ISS). The paper will also offer some historical statistics about the experiments that completed the payload safety process for Shuttle and ISS. The paper 1 then presents the background of ISS agreements and international treaties that had to be taken into account when establishing the ESA PSRP. The detailed franchising model will be expounded upon, followed by an outline of the cooperation charter approved by the NASA Associate Administrator, Office of Space Flight, and ESA Director of Manned Spaceflight and Microgravity. The resulting ESA PSRP implementation and its success statistics to date will then be addressed. Additionally the paper presents the ongoing developments with the Japan Aerospace Exploration Agency. The discussion will conclude with ideas for future developments, such to achieve a fully integrated international system of payload safety panels for ISS.

Heimann, Timothy↗
NASA NTRS2005

The Importance of Multilateral Safety Requirements for Human Spaceflight

The International Space Station (ISS) Program initially implemented safety requirements in a series of bilateral agreements between NASA and each International Partner. As the program matured and multilateral processes began to be developed, the differences between these bilaterally agreed requirement sets became more significant. Efforts to develop multilateral safety requirements were hampered for many reasons including assessment of national standards used in the bilateral agreements, requirements baselines for existing contracts, and resource limitations to address requirements changes late in the development and operations phases. To avoid similar requirements issues in the future, international safety requirements need to be developed for human spaceflight. This paper will provide the background of the ISS bilateral Safety and Mission Assurance requirements and processes, describe the activities to develop multilateral safety requirements and processes, and give examples of issues that were encountered. Further, the paper will make recommendations regarding the development of international safety requirements for human spaceflight and the safety topics to be addressed.

Pido, Kelle↗
NASA NTRS2005

NASA's Software Safety Standard

NASA (National Aeronautics and Space Administration) relies more and more on software to control, monitor, and verify its safety critical systems, facilities and operations. Since the 1960's there has hardly been a spacecraft (manned or unmanned) launched that did not have a computer on board that provided vital command and control services. Despite this growing dependence on software control and monitoring, there has been no consistent application of software safety practices and methodology to NASA's projects with safety critical software. Led by the NASA Headquarters Office of Safety and Mission Assurance, the NASA Software Safety Standard (STD-18l9.13B) has recently undergone a significant update in an attempt to provide that consistency. This paper will discuss the key features of the new NASA Software Safety Standard. It will start with a brief history of the use and development of software in safety critical applications at NASA. It will then give a brief overview of the NASA Software Working Group and the approach it took to revise the software engineering process across the Agency.

Ramsay, Christopher M.↗
NASA NTRS2010

Verification and Implementation of Operations Safety Controls for Flight Missions

There are several engineering disciplines, such as reliability, supportability, quality assurance, human factors, risk management, safety, etc. Safety is an extremely important engineering specialty within NASA, and the consequence involving a loss of crew is considered a catastrophic event. Safety is not difficult to achieve when properly integrated at the beginning of each space systems project/start of mission planning. The key is to ensure proper handling of safety verification throughout each flight/mission phase. Today, Safety and Mission Assurance (S&MA) operations engineers continue to conduct these flight product reviews across all open flight products. As such, these reviews help ensure that each mission is accomplished with safety requirements along with controls heavily embedded in applicable flight products. Most importantly, the S&MA operations engineers are required to look for important design and operations controls so that safety is strictly adhered to as well as reflected in the final flight product.

Smalls, James R.↗
NASA NTRS2010

2009 NASA Range Safety Annual Report

This year, NASA Range Safety transitioned to a condensed annual report to allow for Secretariat support to the Range Safety Group, Risk Committee. Although much shorter than in previous years, this report contains full-length articles concerning various subject areas, as well as links to past reports. Additionally, summaries from various NASA Range Safety Program activities that took place throughout the year are presented, as well as information on several projects that may have a profound impact on the way business will be done in the future. The sections include a program overview and 2009 highlights; Range Safety Training; Range Safety Policy; Independent Assessments Support to Program Operations at all ranges conducting NASA launch operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities.

Source record↗
NASA NTRS2010

2010 NASA Range Safety Annual Report

this report provides a NASA Range Safety overview for current and potential range users. This report contains articles which cover a variety of subject areas, summaries of various NASA Range Safety Program activities conducted during the past year, links to past reports, and information on several projects that may have a profound impact on the way business will be done in the future. Specific topics discussed in the 2010 NASA Range Safety Annual Report include a program overview and 2010 highlights; Range Safety Training; Range Safety Policy revision; Independent Assessments; Support to Program Operations at all ranges conducting NASA launch/flight operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities. Every effort has been made to include the most current information available. We recommend this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. Once again, the web-based format was used to present the annual report.

Dumont, Alan G.↗
NASA NTRS2008

Launch Services Safety Overview

NASA/KSC Launch Services Division Safety (SA-D) services include: (1) Assessing the safety of the launch vehicle (2) Assessing the safety of NASA ELV spacecraft (S/C) / launch vehicle (LV) interfaces (3) Assessing the safety of spacecraft processing to ensure resource protection of: - KSC facilities - KSC VAFB facilities - KSC controlled property - Other NASA assets (4) NASA personnel safety (5) Interfacing with payload organizations to review spacecraft for adequate safety implementation and compliance for integrated activities (6) Assisting in the integration of safety activities between the payload, launch vehicle, and processing facilities

Loftin, Charles E.↗
NASA NTRS2013

Systems Analysis of NASA Aviation Safety Program: Final Report

A three-month study (February to April 2010) of the NASA Aviation Safety (AvSafe) program was conducted. This study comprised three components: (1) a statistical analysis of currently available civilian subsonic aircraft data from the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), and the Aviation Safety Information Analysis and Sharing (ASIAS) system to identify any significant or overlooked aviation safety issues; (2) a high-level qualitative identification of future safety risks, with an assessment of the potential impact of the NASA AvSafe research on the National Airspace System (NAS) based on these risks; and (3) a detailed, top-down analysis of the NASA AvSafe program using an established and peer-reviewed systems analysis methodology. The statistical analysis identified the top aviation "tall poles" based on NTSB accident and FAA incident data from 1997 to 2006. A separate examination of medical helicopter accidents in the United States was also conducted. Multiple external sources were used to develop a compilation of ten "tall poles" in future safety issues/risks. The top-down analysis of the AvSafe was conducted by using a modification of the Gibson methodology. Of the 17 challenging safety issues that were identified, 11 were directly addressed by the AvSafe program research portfolio.

Jones, Sharon M.↗
NASA NTRS2015

Overview of Risk Mitigation for Safety-Critical Computer-Based Systems

This report presents a high-level overview of a general strategy to mitigate the risks from threats to safety-critical computer-based systems. In this context, a safety threat is a process or phenomenon that can cause operational safety hazards in the form of computational system failures. This report is intended to provide insight into the safety-risk mitigation problem and the characteristics of potential solutions. The limitations of the general risk mitigation strategy are discussed and some options to overcome these limitations are provided. This work is part of an ongoing effort to enable well-founded assurance of safety-related properties of complex safety-critical computer-based aircraft systems by developing an effective capability to model and reason about the safety implications of system requirements and design.

Torres-Pomales, Wilfredo↗
NASA NTRS2015

"Evidence" Under a Magnifying Glass: Thoughts on Safety Argument Epistemology

Common definitions of "safety case" emphasize that evidence is the basis of a safety argument, yet few widely referenced works explicitly define "evidence". Their examples suggest that similar things can be regarded as evidence. But the category evidence seems to contain (1) processes for finding things out, (2) information resulting from such processes, and (3) relevant documents. Moreover, any item of evidence could be replaced by further argument. Normative models of informal argumentation do not offer clear guidance on when a safety argument should cite evidence rather than appeal to a more detailed argument. Disciplines such as the law address the problem with a practical, domain-specific epistemology. In this paper, we explore these problems associated with evidence citations in safety arguments, identify goals for a theory of safety argument evidence and a practical safety argument epistemology, propose a model of safety evidence citation that advances the identified goals, and present a related extension to the Goal Structuring Notation (GSN).

Graydon, P. J.↗
NASA NTRS2019

Potential Improvements to the Nuclear Safety and Launch Approval Process for Nuclear Reactors Utilized for Space Power and Propulsion Applications

This study examines potential improvements that could be made to the nuclear safety and launch approval process for fission reactors to reduce the associated uncertainties in cost and schedule while continuing to ensure public safety and environmental protection. It concentrates on the launch approval and mission safety of fission power and propulsion applications of nuclear energy. Improvements to the launch approval process for radioisotope power systems (RPSs) are being considered elsewhere but are acknowledged throughout the report. The study considered technical, process, and organizational improvements to the launch approval processes. The study exclusively evaluated reactors that would not be started up prior to achieving a “sufficiently high orbit,” per United Nations (UN) Resolution 47/68.Potential criticality accidents were considered that could occur during a launch failure or abort or during reentry. Numerous scenarios were examined that might involve one or more Earth flybys as well as potential transportation missions that could intentionally return an active, or previously active fission reactor to Earth orbit. The Study Group was guided in its deliberations according to a number of fundamental principles. These included the paramount importance of adequate and appropriate levels of public safety and environmental protection as well as the importance of the inclusion of independent scientific, engineering, and safety reviews of the applications and proposals as a critical part of the process. Also considered was the need for the development of launch approval processes that might be different, depending upon the source of the application for launch approval, whether it be derived as a governmental launch, a commercial launch, or a hybrid/combination of the two. It is clear that all launches of nuclear reactors into space should have similar safety requirements; however, the safety review effort and the details of the analysis that are required should be commensurate with the potential hazards and the actual risk, which may differ based on the reactor design and its intended purpose. Finally, the study aimed at ensuring that whatever processes and procedures are developed should maximize the sufficiency, simplicity, and transparency of the processes. The Study Group reached five Conclusions and makes thirteen Recommendations. The Conclusions and Recommendations presented here are extensions of those presented previously in other studies. This report attempts to add specificity to the actions that need to be taken in order to move forward with successful space fission reactor programs. Without action to address the perceived and real problems in the launch approval process, designers and mission managers will be reluctant to commit the resources necessary to make space fission reactors a reality.

Camp, Allen↗
NASA NTRS2019

Challenges and Opportunities of International Cooperation for Safety & Mission Assurance (SMA) on the European Service Module (ESM) of the Orion Program

ESA is providing the ESM to NASA for the Orion Program in accordance with the Implementing Arrangement (IA) established between the two Agencies in 2012. This IA is a barter agreement, in which ESA provides Service Module vehicles for the first two flights of Orion in exchange for two servicing missions to the ISS. This arrangement has provided opportunities and challenges to both communities. It represents an important opportunity for ESA to build on its experience in the development and operations of ATV and play an active role in the development and flight of a manned space vehicle. This paper will explore some of the unique aspects of this arrangement as it affects Safety & Mission Assurance (SMA).The assessment of ESM compliance with applicable safety requirements is the responsibility of the Joint Safety and Engineering Review Panel (JSERP). The JSERP has two features that are relatively unique amongst NASA safety panels. First, NASA Engineering and SMA organizations co-chair this Panel. Previously, Safety has chaired, with Engineering as a member of the Panel. Inclusion of Engineering as a co-chair has offered greater leverage within the technical community. Second, the JSERP includes a second set of co-chairs from ESA Engineering and ESA Product Assurance and Safety (PA/S) organizations. This recognizes the international arrangement as one of partnership.Another source of both opportunity and challenge is the differing experience base of ESA and NASA. NASA has decades of experience in manned spaceflight, dating back to the Mercury program and following through Gemini, Apollo, Apollo-Soyuz, Skylab, Shuttle and the International Space Station. The risk posture for manned missions is much more rigorous than for unmanned missions. ESA brings a wealth of knowledge as well, with their flights of Ariane and Automated Transfer Vehicle (ATV), development and operation of the Columbus module on ISS, and satellite programs. The result is that both parties have developed paradigms related to risk and failure that contribute to ESM discussions.Orion represents humanity's first venture beyond Low-Earth Orbit (LEO) in over fifty years. Much of that experience is captured in program documents, but first-hand knowledge is limited to a few spaceflight veterans. Missions to LEO have offered the opportunity of direct, near-instantaneous communications and assistance, and the ability to return to Earth within a matter of hours in case of emergency. Outward-bound missions do not have these features and will require a more autonomous spacecraft with attendant safety-related issues.This paper will explore these and other challenges as we approach the flight of the first Orion vehicle.

Ciancone, Michael L.↗
NASA NTRS2019

NASA's Journey to Safety Culture

One of the organizational causes of the Shuttle Columbia mishap found by the Columbia Accident Investigation Board (CAIB) Report was a "Broken Safety Culture". Since its release, NASA has strived to improve its Safety Culture In 2009, the Chief of the Office of Safety and Mission Assurance asked a member of the Air Force Safety Center and of the CAIB for assistance to develop a NASA Safety Culture Program. This presentation describes the journey that NASA personnel has taken developing a NASA Safety Culture Program to "repair" its Safety Culture.

Dillinger, Tracy↗
NASA NTRS2018

FUELEAP Model-Based System Safety Analysis

NASA researchers, in a partnership with Boeing, are investigating a fuel-cell powered variant of the X-57 “Maxwell” Mod-II electric propulsion aircraft, which is itself derived from a stock Tecnam P2006T. The “Fostering Ultra-Efficient Low-Emitting Aviation Power” (FUELEAP) project will replace the X-57 power subsystem with a hybrid Solid-Oxide Fuel Cell (SOFC) system to increase the potential range of the electric-propulsion aircraft while dramatically improving efficiency and emissions over stock internal-combustion engines. Our FUELEAP safety analysis faces two primary challenges. First, the Part 23 certificated Tecnam P2006T is undergoing significant modifications to host the hybrid electric-propulsion system, and the challenge is to assure that the safety inherent in the stock aircraft (and subsequently in X-57 Mod-II) is not compromised by changes in avionics, aircraft structural loading, weight and balance, or other considerations. Secondly, because the SOFC power system has little (if any) relevant in-service precedent, our challenge is to assure that we identify and mitigate all reasonably plausible hazards introduced by unique FUELEAP equipage. We are investigating and utilizing Model-Based Safety Analysis (MBSA) methods to help us address these FUELEAP safety challenges. We captured aircraft-level system hazard conditions using instances of a SysML hazard block via aircraft-level Functional Hazard Analysis (FHA). Then, using SysML models of the FUELEAP architecture, we related the hazard conditions to initiating system events and possible mitigations, such as design architecture modifications or operational constraints. We are continuing to define our approach to MBSA by developing a component-by-component inventory of local failure modes and tracing their possible contribution to hazard conditions. Finally, we are applying an argument-based approach to FUELEAP assurance. Through a FUELEAP “safety case,” we are providing an explicit argument for FUELEAP safety by associating assurance evidence with overarching safety claims through a structured argument.

Woodham, Kurt P.↗